Kerem Shuval

Sedentary behavior, cardiorespiratory fitness, physical activity, and cardiometabolic risk in men: the cooper center longitudinal study.

OBJECTIVE To examine the association between sedentary behavior and cardiometabolic risk, while taking into account cardiorespiratory fitness (fitness) and physical activity. PARTICIPANTS AND METHODS We examined the association of sedentary behavior, physical activity, and fitness (exposure variables) to cardiometabolic biomarkers and metabolic syndrome (outcome measures) among a historic cohort (January 2, 1981, through October 16, 2012) of men. First, we estimated the association (cross-sectionally and longitudinally) of sedentary behavior along with physical activity and fitness to lipids and lipoproteins, glucose, blood pressure, and markers of adiposity, including body mass index, waist circumference, and body fat percentage. We then prospectively examined the effects of baseline sedentary time on the incidence of metabolic syndrome, while adjusting for physical activity, fitness, and other covariates in multivariate models. RESULTS Multivariate analysis of baseline data revealed that in comparison with the reference group (≤9 h/wk of sedentary time), more sedentary behavior was significantly associated with a higher triglyceride level, a higher triglycerides-high-density lipoprotein cholesterol ratio, and a higher body mass index, waist circumference, and body fat percentage (P<.05 for trend), after adjusting for physical activity and covariates. When adjusting for fitness and covariates, prolonged sedentary time was only associated with a higher triglyceride-high-density lipoprotein cholesterol ratio (P=.02 for trend). Sedentary time was not associated with the incidence of metabolic syndrome in multivariate models. Longitudinal analyses revealed that a 1-metabolic equivalent increase in fitness was significantly (P<.05) associated with almost all biomarkers when adjusting for sedentary behavior, with little moderation observed. CONCLUSION The association between prolonged sedentary time and cardiometabolic biomarkers is markedly less pronounced when taking fitness into account. Further exploration of the effects of sedentary behavior on cardiometabolic risk is warranted in cohorts with available fitness data. Furthermore, our findings underscore the need to encourage achieving higher fitness levels through meeting physical activity guidelines to decrease disease risk factors.

Community Diabetes Education (CoDE) for uninsured Mexican Americans: A randomized controlled trial of a culturally tailored diabetes education and management program led by a community health worker

AIMS The purpose of this randomized controlled trial was to determine the impact of a culturally tailored diabetes education program led by a community health worker (CHW) on the HbA1c, blood pressure, body mass index (BMI) and lipid status of uninsured Mexican Americans with diabetes. METHODS Adult patients were recruited from a community clinic and randomized into intervention (n=90) and control (n=90) groups. Both groups received usual medical care from clinic physicians. The intervention group participated in the Community Diabetes Education (CoDE) program over 12 months. The primary outcome of interest was HbA1c. Secondary outcomes included blood pressure, BMI and lipid status. Variations in outcomes over time were assessed within groups and between groups using linear mixed-models and an intention-to-treat approach. Assessment of changes in HbA1c, blood pressure and lipid status over 12 months included variables to control for modifications made to antidiabetic, antihypertensive and lipid lowering medications. RESULTS There was no difference in baseline characteristics between the intervention and control groups. Mean changes of HbA1c over 12 months showed a significant intervention effect (-.7%, p=.02) in the CoDE group compared with controls. HbA1c decreased significantly from baseline to 12 months within the intervention (-1.6%, p<.001) and control (-.9%, p<.001) groups. No differences between groups for secondary outcomes were found. CONCLUSIONS This study supports the effectiveness of CHWs as diabetes educators/case managers functioning as integral members of the health care team in community clinic settings serving uninsured Mexican Americans.

The GoodNEWS (Genes, Nutrition, Exercise, Wellness, and Spiritual Growth) Trial: A community-based participatory research (CBPR) trial with African-American church congregations for reducing cardiovascular disease risk factors — recruitment, measurement, and randomization

INTRODUCTION Although cardiovascular diseases (CVD) are the leading cause of death among Americans, significant disparities persist in CVD prevalence, morbidity, and mortality based on race and ethnicity. However, few studies have examined risk factor reduction among the poor and ethnic minorities. METHODS Community-based participatory research (CBPR) study using a cluster randomized design--African-American church congregations are the units of randomization and individuals within the congregations are the units of analysis. Outcome variables include dietary change (Diet History Questionnaire), level of physical activity (7-Day Physical Activity Recall), lipoprotein levels, blood pressure, fasting glucose, and hemoglobin A1c. RESULTS Eighteen (18) church congregations were randomized to either a health maintenance intervention or a control condition. Complete data were obtained on 392 African-American individuals, 18 to 70 years of age, predominantly employed women with more than a high school diploma. Treatment and intervention groups were similar at baseline on saturated fat intake, metabolic equivalent of tasks (METS) per day, and other risk factors for CVD. CONCLUSIONS The GoodNEWS trial successfully recruited and evaluated CVD-related risk among African-American participants using a CBPR approach. Several logistical challenges resulted in extending the recruitment, preliminary training, and measurement periods. The challenges were overcome with the assistance of a local community consultant and a professional event planner. Our experience supports the need for incorporating non-traditional community-based staff into the design and operational plan of CBPR trials.

The Supplemental Nutrition Assistance Program and Dietary Quality Among US Adults: Findings From a Nationally Representative Survey

OBJECTIVE To examine the association of the Supplemental Nutrition Assistance Program (SNAP) and diet quality among low-income adults. PATIENTS AND METHODS We examined US nationally representative data from the National Health and Nutrition Examination Surveys 2003-2004, 2005-2006, 2007-2008, and 2009-2010. The data were analyzed from October 7, 2013, to March 1, 2014. The analytic sample consisted of 4211 low-income adults aged 20 to 64 years, of whom 1830 participate in SNAP. We adhered to the National Cancer Institute method in calculating the Healthy Eating Index 2010 and other dietary indicators, such as empty calorie intake. Bivariate and multivariable regression was used to compare SNAP participants and income-eligible nonparticipants among the full sample and subsamples of age, sex, race/ethnicity, and food insecurity. RESULTS Compared with low-income nonparticipants, adjusted analyses reveal that SNAP participants had lower dietary quality scores overall (42.58 vs 44.36, P≤.0001) and lower scores for fruits and vegetables, seafood and plant proteins (1.55 vs 1.77, P≤.0022), and empty calories (9.03 vs 9.90, P≤.0001), but they exhibited comparable scores on whole grain, refined grain, total dairy, total protein, fatty acid, and sodium intakes. The association between SNAP participation and lower dietary quality was statistically significant among women, Hispanics, young adults, and individuals who were food secure. CONCLUSION Our analyses suggest that SNAP participants have lower dietary quality than their income-eligible nonparticipant counterparts. Although SNAP has an important role in providing nutrition assistance to eligible low-income individuals, interventions are warranted to improve the dietary quality of participants.

The Supplemental Nutrition Assistance Program, Food Insecurity, Dietary Quality, and Obesity Among US Adults

OBJECTIVES We examined whether Supplemental Nutrition Assistance Program (SNAP) participation changes associations between food insecurity, dietary quality, and weight among US adults. METHODS We analyzed adult dietary intake data (n = 8333) from the 2003 to 2010 National Health and Nutrition Examination Survey. Bivariate and multivariable methods assessed associations of SNAP participation and 4 levels of food security with diet and weight. Measures of dietary quality were the Healthy Eating Index 2010, total caloric intake, empty calories, and solid fat; weight measures were body mass index (BMI), overweight, and obesity. RESULTS SNAP participants with marginal food security had lower BMI (1.83 kg/m2; P < .01) and lower probability of obesity (9 percentage points; P < .05). SNAP participants with marginal (3.46 points; P < .01), low (1.98 points; P < .05), and very low (3.84 points; P < .01) food security had better diets, as illustrated by the Healthy Eating Index. Associations between SNAP participation and improved diet and weight were stronger among Whites than Blacks and Hispanics. CONCLUSIONS Our research highlights the role of SNAP in helping individuals who are at risk for food insecurity to obtain a healthier diet and better weight status.

Impediments and Facilitators to Physical Activity and Perceptions of Sedentary Behavior Among Urban Community Residents: The Fair Park Study

Introduction Insufficient physical activity is an established risk factor for numerous chronic diseases and for premature death. Accumulating evidence reveals that prolonged sedentary time is detrimental, independent of the protective effects of physical activity. Although studies have explored correlates of physical activity among ethnic minority populations, few have examined factors related to sedentary behavior. Therefore, we conducted a preliminary investigation into urban adults’ perceptions of sedentary behavior alongside perceived barriers and enablers to physical activity. Methods In-depth semi-structured interviews were used to evaluate perceptions of physical activity and sedentary behavior in a sample of low-income, ethnic minority adults. The framework approach guided researchers in analyzing the qualitative data. Results Participants were well aware of the positive health benefits of physical activity. However, most admitted not regularly engaging in physical activity and cited numerous barriers to activity, such as lack of time, insufficient finances, and neighborhood crime. Enablers included weight loss, the presence of social support, and the availability of safe parks conducive to exercise. In comparison, participants were primarily unfamiliar with the term “sedentary behavior” and did not perceive a relationship between sedentary behavior and health outcomes. Conclusion Our findings illustrate the need to increase the awareness of negative health implications of prolonged sedentary time while continuing to address the multiple impediments to physical activity as a way to combat chronic disease.

Impact of a Mobile Phone Intervention to Reduce Sedentary Behavior in a Community Sample of Adults: A Quasi-Experimental Evaluation

Background Greater time spent sedentary is linked with increased risk of breast, colorectal, ovarian, endometrial, and prostate cancers. Given steadily increasing rates of mobile phone ownership, mobile phone interventions may have the potential to broadly influence sedentary behavior across settings. Objective The purpose of this study was to examine the short-term impact of a mobile phone intervention that targeted sedentary time in a diverse community sample. Methods Adults participated in a quasi-experimental evaluation of a mobile phone intervention designed to reduce sedentary time through prompts to interrupt periods of sitting. Participants carried mobile phones and wore accelerometers for 7 consecutive days. Intervention participants additionally received mobile phone prompts during self-reported sitting and information about the negative health impact of prolonged sedentariness. The study was conducted from December 2012 to November 2013 in Dallas, Texas. Linear mixed model regression analyses were conducted to evaluate the influence of the intervention on daily accelerometer-determined estimates of sedentary and active time. Results Participants (N=215) were predominantly female (67.9%, 146/215) and nonwhite (black: 50.7%, 109/215; Latino: 12.1%, 26/215; other: 5.6%, 12/215). Analyses revealed that participants who received the mobile phone intervention had significantly fewer daily minutes of sedentary time (B=–22.09, P=.045) and more daily active minutes (B=23.01, P=.04) than control participants. Conclusions A simple mobile phone intervention was associated with engaging in less sedentary time and more physical activity. Findings underscore the potential impact of mobile phone interventions to positively influence sedentary behavior and physical activity.

Health behavior and behavioral economics: economic preferences and physical activity stages of change in a low-income African-American community.

Purpose. To examine the relationship between physical activity stages of change and preferences for financial risk and time. Design. A cross-sectional, community-based study. Setting. A low-income, urban, African-American neighborhood. Subjects. One hundred sixty-nine adults. Measures. Self-reported physical activity stages of change—precontemplation to maintenance, objectively measured body mass index and waist circumference, and economic preferences for time and risk measured via incentivized economic experiments. Analysis. Multivariable ordered logistic regression models were used to examine the association between physical activity stages of change and economic preferences while controlling for demographic characteristics of the individuals. Results. Individuals who are more tolerant of financial risks (odds ratio [OR] = 1.31, p < .05) and whose time preferences indicate more patience (OR = 1.68, p < .01) are more likely to be in a more advanced physical activity stage (e.g., from preparation to action). The likelihood of being in the maintenance stage increases by 5.6 and 10.9 percentage points for each one-unit increase in financial risk tolerance or one-unit increase in the time preference measure, respectively. Conclusion. Greater tolerance of financial risk and more patient time preferences among this low-income ethnic minority population are associated with a more advanced physical activity stage. Further exploration is clearly warranted in larger and more representative samples.

‘Sedentary behaviour counselling’: the next step in lifestyle counselling in primary care; pilot findings from the Rapid Assessment Disuse Index (RADI) study

Background Accumulating evidence emphasises a relationship between prolonged sitting and increased risk for cardiometabolic disorders and premature death irrespective of the protective effects of physical activity. Primary care physicians have the potential to play a key role in modifying patients’ sedentary behaviour alongside physical activity. Methods A pilot study examining sedentary behaviour and physical activity counselling in a primary care clinic. A total of 157 patients completed a detailed survey related to lifestyle counselling received from their primary care physician. We analysed these responses to describe counselling practices within the 5A framework, and to examine correlates (ie, patients’ demographics, sedentary behaviour and physical activity and clinical variables) related to receiving counselling. Results A total of 10% received general advice to decrease sitting time, in comparison with 53% receiving general physical activity counselling. None, however, received a written plan pertaining to sedentary behaviour whereas 14% received a written physical activity prescription. Only 2% were provided with specific strategies for sedentary behaviour change in comparison with 10% for physical activity change. Multivariable analysis revealed that patients who were obese were more likely to receive counselling to decrease sitting (OR=7.0; 95% CI 1.4 to 35.2). In comparison, higher odds for receiving physical activity counselling were associated with being younger, aged 40–59 years (OR=2.4; 95% CI 1.1 to 5.4); and being a non-smoker (OR=6.1; 95% CI 1.3 to 28.4). Conclusions This study is the first to assess sedentary behaviour counselling practices in primary care and such practices appear to be infrequent. Future research should attempt to establish a ‘knowledge base’ to inform development of sedentary behaviour interventions, which should be followed by testing feasibility, efficacy, and subsequent effectiveness of these programmes in a clinical setting.

Do stressful events account for the link between socioeconomic status and mental health

BACKGROUND The purpose of this study was to prospectively examine the relationships between socioeconomic status (SES), demographic variables and mental health and to determine whether number of life stressors mediated these relationships. METHODS Wave 1 (2001-02) and 2 (2004-05) data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; n = 34,459) were used in the current study. Controlling for wave 1 mental health, a mediation model was tested to determine the relative impact of socioeconomic and demographic variables (all measured at wave 1) on mental health 3 years later (wave 2). The number of life stressors experienced in the 12 months prior to wave 1, assessed at wave 1, was evaluated as the mediator. RESULTS Findings indicated that SES, age, race/ethnicity, gender and marital status independently predicted changes in mental health ratings at wave 2. In addition, the number of life stressors mediated the relation between socioeconomic and demographic variables and mental health. Exposure to life stressors helps to explain commonly reported socioeconomic and demographic disparities in mental health. CONCLUSIONS Findings may suggest that reducing exposure to stressors and/or improving coping with life stressors may both improve mental health and reduce health disparities.